Summary of Aledade’s Comments on the Proposed Physician Fee Schedule for 2022
September 15, 2021

Written by Casey Korba, Director of Policy

It’s Physician Fee Schedule (PFS) comment season, and that means Aledade has been working to finalize and submit our comments to CMS on the Proposed PFS for 2022. You can read the full 23-page letter here. For those of you who want a quicker summary, you’ve come to the right place. 

Our main recommendations to CMS are:

  • Improve the MSSP benchmarking methodologies to support ACOs serving vulnerable populations and those in rural areas
  • Stop the transition of MSSP Quality Reporting to MIPS APP, which is leading to less accurate measurement, confusion and administrative burden
  • Keep telehealth flexibilities and prepare for the future of telehealth
  • Continue to improve Chronic Care Management

We also included our response to the Closing the Health Equity Gap in CMS Clinician Quality Program Request for Information (RFI). 


Medicare Shared Savings Program

Don’t Wait to Fix Benchmarking Problems

Aledade identified the “rural glitch” back in 2018. Inclusion of Medicare beneficiaries in regional trends and benchmarks disproportionately harms rural ACOs and other ACOs with market shares above the MSSP average. The fix is straightforward: remove an ACO’s assigned beneficiaries from its regional benchmark and its regional trend. We point out that CMS’s proposed mathematical solution works well in nearly every case and uses data CMS already produces. We also outline how the current risk cap policy harms those treating Medicare’s most vulnerable beneficiaries, as ACOs who disproportionately serve the disabled and the aged-dual populations are harmed twice as much by the current policy. More in-depth analysis of the rural glitch can be found in our recent white paper. In our comments, we urge CMS to act now to implement the solutions outlined in the proposed rule and not wait for future rulemaking.

Quality Reporting in MSSP: Do Not Move ACOs to MIPS 

We urge CMS to abandon the strategy of aligning ACO quality with MIPS quality assessments, referred to as the APM Performance Pathway (APP). Tying the MSSP ACO quality performance standard to a MIPS final quality category score percentile is an inaccurate comparison and confusing. An ACO could score in the 80th percentile on every individual measure and be below the 30th percentile overall. This grading on a curve with an unrepresentative comparison group is not good policy.


Prepare for the Future of Telehealth 

While we applaud the lifting of telehealth restrictions during the public health emergency, we point out that many of the practices we partner with have been confused by the multiple timelines CMS has created and ask that CMS adopt the longest uniform time frame possible when thinking through expanding telehealth flexibilities. 

The pandemic has demonstrated that telehealth is critical to addressing the mental health shortage. We ask that CMS replace the proposed 6-month follow-up timeframe for in-person visits following a telehealth mental health visit with a 12-month in-person follow-up or a primary care in-person visit. In-person primary care and virtual mental health services can be a powerful combination.

Finally, we recognize that the pandemic has permanently altered the telehealth landscape and there is no going backwards. We ask that CMS begin the process of creating payment amounts that accurately reflect the provision of telehealth as delivered by providers who also deliver health care services face-to-face in an office setting in preparation for Congressional action on telehealth in the future. More details on our proposed solution for telehealth can be found here.


Reduce Barriers to Chronic Care Management 

Aledade has long applauded CMS for recognizing Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. We ask that CMS simplify documentation through clarifying that a care plan meeting the requirements can be created at a previous annual wellness visit or other visit and does not have to be tied directly to the first CCM service. 

We state that the cost-sharing requirement for CCM is a barrier for beneficiaries. While we understand that CMS does not have the full authority to waive the coinsurance obligation for beneficiaries, we ask that CMS consider issuing guidance or FAQs that provide clarity for providers on what flexibilities they might have to handle co-insurance under CCM. 


Advance Health Equity 

Aledade believes that physician-led accountable care organizations are extremely well-positioned to address health equity through a value-based care system that is effective in reducing costs and improving quality. Our comments support CMS’s proposal to update the complex patient bonus formula and reward physicians who see a higher percentage of high-need patients. We also discuss the importance of collecting data on social determinants of health through better incentives and standards. We add that providers should be reimbursed for social determinants of health screenings to increase uptake. We point out that many independent practices and CHCs are facing staffing shortages, issues that have been made worse by the pandemic. We suggest that CMS address staffing issues more in-depth in future RFIs, as this is a direct tie to data collection and related processes. 


Next Steps for Aledade

The comment period has closed and CMS will begin the work of going through the 35,000+ comments received on the Proposed PFS. CMS will likely publish the final PFS in November, and we will keep you informed of what is in the final regulation. 

In the meantime, Aledade will continue to push for fixes to the rural glitch and other initiatives to strengthen value-based care and ACOs through Congress, by advocating for two bi-partisan bills, Accountable Care in Rural America Act and the Value in Health Care Act. We will continue to work with Congress, CMS and our partner stakeholders to make evidence-based, data-driven improvements to the MSSP.